clinical microsystems and lean - rjl.se
TRANSCRIPT
Kyle E. Hultgren, PharmDManaging Director
Purdue University College of PharmacyCenter for Medication Safety Advancement
Clinical Microsystems and Lean
Clinical Microsystem
“… a small group of people who work together on a regular basis – or as needed – to provide care and the individuals who receive that care… It has clinical and business aims, linked processes, a shared information environment and produces services and care which can be measured as performance outcomes.”
Clinical Microsystem Action Guide ©2004, Trustees of Dartmouth College, Godfrey, Nelson, Batalden
The Path Forward
Step 1: Organize a “Lead Team”Step 2: Do the Assessment
Use the “5Ps” and review your Metrics That Matter
Step 3: Make a DiagnosisReview your assessment and select a theme for improvement
Step 4: Treat Your MicrosystemStep 5: Follow-upClinical Microsystem Action Guide ©2004, Trustees of Dartmouth College, Godfrey, Nelson, Batalden
Lean AND Clinical Microsystems
What Lean Healthcare is NOT…The answer to ALL of your problemsDoing “more with less”A replacement for the 5P’sJust a manufacturing problem solving toolA bunch of “tools” for problem solving
A “Lean” Overview of Lean
The Toyota Production System (TPS)The Toyota Way – Jeffrey Likero Outlines 14 principles of the Toyota Way
• Philosophy• Process• People and Partners• Problem Solving
What is Lean?
“Lean provides a way to specify value, line up value creating actions in the best sequence, conduct these activities without interruption whenever someone requests them, and perform them more and more effectively.”
-from Lean Thinkingby James Womack and Daniel Jones (1996)
Start Step 1 WASTE WASTE Step 2 Finish
TIME
Start Step 1 Step 2 Finish
TIME
Lean is a systems redesign methodology that shortens the time between start and finish of any given process by eliminating sources of waste.
Lean – Another Perspective
Lean Concepts
Valueo Value is determined by the “end customer” – the patient
Identify and eliminate waste o Anything that does not add value from the patient’s
perspective
Value flows without interruptiono Identify ideal patient experience – streamline process and
eliminate waste to achieve
Allow customer to “pull” value from processo Available when they want it – one piece flow
Continuous pursuit of perfectiono Reliable and sustainable systems design
Specify Value
No delays in access to care – no scheduled waitingAccurate, consistent, satisfying outcomesFlexible No waiting to see provider
No delays in access to patients – full scheduleAll charts, labs, and pertinent information readily available Patients are geographically close together (inpatient)
Patient Perspective Provider Perspective
Patient Provider
Typically 95% of Health Care Process Typically 95% of Health Care Process Time is nonis non--value added!!!value added!!!
The Eight Forms of Waste• Defects• Overproduction• Waiting• Not Utilizing Employees• Transportation• Inventory• Motion• Extra Processing
Value added
Non-value added
5%
Lean = Eliminating the Waste
Defects
Hospital-acquired illnessWrong-site surgeriesMedication errorsForeign objects remaining in patient after surgeryProblem ordersMisfiling documentsDealing with service complaintsMistakes resulting from miscommunicationIllegible, handwritten informationCollection of incorrect patient information
Overproduction
Too many meal trays deliveredAsking the patient the same questions multiple timesLarge supply of formsExtra floor space utilizedUnnecessary carbon copyingBatch printing patient labels
Waiting
Idle machines/peopleLarge waiting roomsPatients waiting to see physician, nurse, etc.Waiting on the phone to schedule patientsEarly admissions for procedures later in the dayWaiting for internal transport between departments
Not Utilizing Human Potential
Not using people’s mental, creative, and physical abilitiesStaff not involved in redesigning processes in their workplaceWorkaroundsNurses and Doctors spending time locating equipment and suppliesStaff rework due to system failures
Transportation
Poor workplace lay-out for patient servicesCarrying files from location to locationMoving equipment in and out of procedure or operation roomPatient transportation
Inventory and Inspection
Office supplies stored in hallwaysCharge slips piled up to be dictatedPhysician orders building up to be enteredUnnecessary instruments contained in operating kitsMultiple quality control checksMuch rework
MotionLeaving patient rooms to o get supplies or recordo document care providedLarge reach/walk distanceDocumenting in more than one placeNurse checking electronic medication record to see if order entry is completedUsing separate IS systems for one process
Extra Processing
Multiple signature requirementsExtra copies of formsMultiple information systems entriesPrinting hard copy of report when digital is sufficientMultiple steps to get pre-approval for urgent treatmentsOverstocking inventory
CASE: Batching Sterile Compounds
Medium-sized hospital prepares 24 hour batches of IV medicationsDeemed a “better use of our night staff” to compound in advance of when meds actually neededAverage daily volume is 600 dosesAverage daily return rate is near 35%
~600 IVs to compound daily
Techs deliver before 1200
Bring back all waste
Batch System
24 hour batch at 0200
2 FTE RPh – 2HTeam writes new orders
Compound/dispense new meds
The life of a Pharmacy Technician
21 Used with permission of H. Woodward-Hagg
Necessary Changes
Standardize the work – policies, procedures, and workspaces that ensure standard outcomesMove from a batch delivery to a one-piece flow delivery of medicationsImplement visual controls in unit med rooms and pharmacy to smooth transition
Hosp Pharm. 2009;44(11):974-977.
One-Piece Flow
Standard timing on the hour, doses print 3H prior to patient need
RPh checksDoses delivered hourly to units
Only one dose available for administration
Returns dropped from 35% to less than 3%
Paperwork Simulation
Sit in teams of 4Choose roles – Person A, B, C, and DWhen the time starts, turn over the cardsPerson A
Must complete ALL three cards before passing on to Person B
Person BMust complete ALL three cards before passing on…
4 minute time limit
Paperwork Simulation – Round 2Same roles – Person A, B, C, and D
When the time starts, turn over the cardsDo NOT have to complete all cards before passing them on4 minute time limit
Five “S”SortSimplify (Set in Order)StandardizeSweep (Shine)Sustain (Self Control)
NOTScroungeStealStashScrambleSearch
5S Workplace Organization
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Before 5S
Touch everythingSeparate necessary from unnecessaryRemove clutterFree up floor spaceEliminate obsolete itemsDo not keep “just in case”
Sort
Remove and Red Tag Items not used or excess supplies
Sort
Organize items by frequency of useAssign items to locationsMark “home” locations for movable objects
Outline if possibleWhite boards for tracking shared itemsSet inventory limits & refill triggers
Simplify
Simplify and Standardize Flow
Color Coding and Two-Bin
• Two small bins instead of one large• Empty bin triggers resupply
Establish visual controls to differentiate normal from abnormal conditionsEstablish “shine” schedules and accountabilityMonitor adherence
Shine
Simplify and Shine
Establish written documentation for all processes and proceduresUse pictures to document desired stateMonitor adherence to standards
Standardize
Pittsburg VA –Equipment Room
BEFORE
BenefitsBenefitsClean equipment = pathogen vector
Saves frustration, searching
Freed up $20K-worth of unused equipment for use elsewhere
IV Pumps (4)
Always Plugged In
AFTER
Whiteboard indicates location
Adapted from materialsCourtesy of Peter Woodbridge
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Create communication boardUse communication boardConduct periodic auditsConduct failure mode analysis and take corrective action when problems found during audits
Sustain
Place for Water Jug
Place for IV Bags
Laminated Instructions
Common Supplies
Medication Cart –Post 5S Mock-up
Baseline / Outcomes Data
Baseline Post-RPIW
Distance traveled to pass meds to one patient 181 33Number of attempts before med pass complete for one patient 3.3 1.0Totals log-ins per patient med pass 10 3Total time to pass meds to one patient 18 3
Time saved for other patient care activities = 15 min x 100 ADC x 3 shifts x 365 = 27,375 hours per year
More Examples
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A3 Problem Solving Methodology
